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A Story for Our Times

The late Todd Graham, MD, in South Bend, Indiana, was primarily a physiatrist, and devoted only a small portion of his practice to pain management. According to his best friend, Dr Graham was trying to phase out of pain management completely because of how the opioid abuse epidemic had changed that field over the years.

“Patients have become more difficult,” said A. J. Mencias, MD,”A lot of them don’t react so well when you deny them opioid painkillers.”
Sometimes relatives of pain patients who hear the word ‘no’ don’t react so well either, which happened to Dr Graham, a popular 56-year-old physician. He was shot to death on July 26 by the husband of a patient whose request for opioid painkillers he denied earlier that day. The patient’s husband, Michael Jarvis, then took his own life.
Dr Graham’s murder highlights the risk for physical violence faced by pain-management physicians, particularly as they and others come under increasing pressure to avoid prescribing opioids for chronic pain. The extent of that risk is a matter of study and conjecture. In a survey of members of the American Society of Interventional Pain Physicians (ASIPP) published in Pain Medicine in 2015, 52% said patients had threatened them, usually in the context of opioid medications, and 7% of the threats involved a gun. Sixty-five percent of ASIPP members have had to call security. Almost 3% reported being injured by a patient. And 8% said they carry a gun for protection.
Whether pain-management physicians say the ASIPP survey underestimates or overestimates the problem of belligerent and sometimes violent patients, the specialty nevertheless has its guard up, training clinicians on how to de-escalate angry confrontations and developing strategies to avoid them in the first place. The risk, in short, is real, said Edward Michna, MD, who serves on the board of directors of the American Pain Society (APS).

Tracked Down in the Parking Lot

At the time of his death, Dr Graham practiced at South Bend Orthopaedics, where he was a partner. He took a multimodal approach toward pain management, relying on everything from physical therapy to antidepressants, said Dr Mencias. “He believed in opioids for short-term therapy.”
Dr Graham, he said, had an excellent bedside manner, and patients’ reviews posted on the South Bend Orthopaedics website seem to bear that out. “Dr Graham…has always been very good at explaining my problems, answering my questions and explaining the treatments,” one patient wrote. “This is done with a pleasant, friendly demeanor and interest.” His patient satisfaction score was 4.3 out of 5. A few patients commented that Dr Graham seemed in a rush, although others said he took his time.
Outside of medicine, Dr Graham lived a full life. He and his wife Julie raised money for charities like a local center for people with intellectual and developmental disabilities, and he consulted with the University of Notre Dame’s athletic department on a volunteer basis. He skied. He played golf. He vacationed in Switzerland, southern France, and St Barthélemy Island in the Caribbean.
On July 26, Dr Graham had an appointment with the wife of 48-year-old Michael Jarvis, who accompanied her. Jarvis also was in chronic pain, and unemployed, according to St Joseph County (Indiana) Prosecuting Attorney Ken Cotter.
It wasn’t the couple’s first visit with Dr Graham. They had been in his office about a month before, with the wife seeking relief for chronic pain, Cotter told Medscape Medical News.
Dr Graham declined to prescribe opioid painkillers at that time, sparking a “strong disagreement” with Michael Jarvis, said Cotter. “He didn’t like the answers.”
The same scene played out on July 26. Dr Graham turned down the wife’s request for opioid painkillers, explaining that they weren’t appropriate for her chronic pain. “She understood, and didn’t want them either,” Cotter said about the conclusion of the second visit. “But [the husband] was insistent.”
The couple left, only for the husband to return to the office 2 hours later with a semiautomatic handgun. He intercepted Dr Graham as he was driving to an adjacent rehabilitation center and exchanged words with him. Jarvis followed Dr Graham and shot him twice in the head in a parking lot after the physician stepped out of his vehicle. Jarvis then drove to a friend’s house, where he committed suicide.
According to Cotter, there’s no evidence to suggest that Jarvis’ wife was involved in her husband’s murderous plan, or knew about it. “She’s suffering, too,” he said in a news conference shortly after the shooting.

“I Know Where You Live”

By all accounts, when a physician denies a request for opioid painkillers, hostile responses usually come from the patient, not a relative. Either way, the responses can be unnerving.
“Anybody who practices pain medicine has been threatened,” said Dr Michna, also an anesthesiologist and pain specialist at Brigham and Women’s Hospital in Boston, Massachusetts. “I’ve received notes saying, ‘I know where you live and that you have children.’ ”
Sometimes ire is sparked when a physician ends someone’s opioid therapy after discovering that the patient is taking illicit drugs as well. Another potentially combustible situation arises when a long-time prescriber of opioid painkillers retires, and a younger replacement tries to wean patients off the drugs. The risk for belligerent behavior, threats, and violence reflects the demographics of patients in pain, according to Dr Michna and others.
“Close to 70% of pain patients have psychological comorbidities, like addictive behavior,” he said. “Many have been in prison. They’re desperate.”
To Dr Michna, the ASIPP finding that 52% of pain-management physicians have been threatened seems low. In contrast, Joanna Katzman, MD, MSPH, president of the Academy of Integrative Pain Management (AIPM), thinks the figure is too high, especially in light of her own experience. Dr Katzman directs the University of New Mexico Pain Center in Albuquerque.
“We have no violence whatsoever,” said Dr Katzman, a professor of neurology at the University of New Mexico School of Medicine, in an interview with Medscape Medical News. “Verbal threats are very rare.”
She credits the peaceful atmosphere to patients knowing that her pain center does not prescribe opioids on the first visit, and that these drugs are far down on the list of possible treatments, which are interdisciplinary in nature. “If all this is laid out from the beginning, there are not unmet expectations,” Dr Katzman said.
Dr Michna at the APS agrees with that approach, saying that it has lowered the level of conflict and anger at his hospital. “Be upfront and mitigate false expectations,” he said.

Just Don’t Take Away Something

Another key to averting blowups over opioids is caring communication with patients, said Steve Stanos, DO, president of the American Academy of Pain Medicine.
For one thing, busy physicians need to stop looking at the clock and take time to explain why a patient is not a candidate for opioid therapy, Dr Stanos told Medscape Medical News. But the length of the conversation is not enough.
“You need to build rapport with patients, and win their trust,” said Dr Stanos, medical director of pain services at the Swedish Health System in Seattle, Washington. “When you don’t prescribe them opioid painkillers, you want to be seen as someone who’s looking out for their best interests instead of taking something away from them.”
What’s valuable with pain patients is motivational interviewing, in which the physician helps the patient in a nonconfrontational way to examine self-defeating behaviors and find the inner motivation to change them. “You want patients to manage themselves,” said Dr Stanos.
A pain-management physician can do all the right things, however, and still have a patient raise his or her voice, face reddening, hands waving. A bit of venting is tolerable, but at some point, a clinician may need to defuse the situation by bringing another person — a behavioral health expert, say — into the discussion, said Dr Stanos. Sometimes Dr Stanos will leave the room momentarily to let the patient decompress, and mull over what he’s said. And sometimes he announces that he will end the interview in so many minutes, and offer to make a follow-up appointment.
Of course, it may boil down to calling security, or the police. Threats of physical violence can’t be tolerated, said the AIPM’s Dr Katzman. Even at the University of New Mexico Pain Center, where threats are rare, staff get periodic training on how to handle a volatile patient. Krishna Chari, PsyD, a clinical psychologist at the center who has coached colleagues on emergency responses, said that a physician can simply tell the patient, “I don’t feel safe” and leave the room.

Packed Funeral Service

South Bend Orthopaedics closed its doors on July 26 shortly after Dr Graham’s murder, and stayed closed the next day. The group practice shut down again on July 31, the day of Dr Graham’s funeral.
Hundreds of mourners, including many patients, filled St Pius X Catholic Church in Granger, Indiana. Dr Mencias recalled how Dr Graham and his electric personality “lit up a room like the sky on the Fourth of July.” Travis Graham, MD, one of Dr Graham’s three adult children and an anesthesiology resident, said in a statement that he had planned to join his father as a physician in South Bend. “I hope I can be the kind of doctor he can be proud of,” the son said.
Dr Mencias said resuming work at the orthopedics practice has been surreal.
“All of my partners and I are nervous,” he said. “You hope that Dr Graham’s murder is a once-in-a-lifetime incident.”
Even so, just a few days after the shooting, a local emergency-department physician was threatened by a patient after he turned down a request for opioid pain medicine, according to Dr Mencias. This time around, no harm came to the physician, and the patient was arrested.

Relapse is NOT a Failure

It is heartbreaking when someone you know has a relapse after some period of successful recovery. The hope generated by the period of sobriety is smashed and the pain comes flooding back. it is disheartening and frustrating. We tend to second guess our future and become angry and resentful. We start to proceed through the stages of grief once again and wonder why this happened.
Here are five things you need to know about relapse courtesy of The Partnership for Drug Free Kids

1. Relapse is common. Although relapses are not inevitable, they are common. Many
people have one or more relapses before achieving long-lasting sobriety or abstinence.
This does not mean the end of efforts toward abstinence and recovery. The person
needs to get back into treatment and the family needs to continue attending a support
group, professional counseling, or both.
2. Work together to prevent relapse. People in recovery may have frequent urges to drink
or use drugs, and feel guilty about it, even though these urges are a normal part of
recovery. It’s important to work together to anticipate high-risk situations (such as a party
where alcohol will be served) and plan ways to prevent them.
3. Relapse can happen during good times, too. Sometimes relapse occurs when the
person is doing well with their recovery. He or she feels healthy, confident, and/or “cured”
and believes that he or she is ready to go back to casual, regular or “controlled” use of
drugs or alcohol. The person may remember the honeymoon period of their use (even
though it may have been long ago) — where his or her use didn’t cause problems and
may want to return to that place. But this is often impossible since addiction changes the
physical makeup of the brain and the person is recovery is no longer able to use drugs or
alcohol in a controlled fashion.
4. If relapse occurs. Medical professionals, particularly those who specialize in substance
use disorders, are an extremely important asset during a time of relapse. They can help
the person learn techniques for containing feelings, focusing on the present, and making
use of support from others. Relying on group support from Twelve Step programs,
engaging in prayer or meditation, and finding other ways to stay on an even keel can also
be extremely helpful.
5. Learn from relapse. Experts have found that a relapse can serve as an important
opportunity for the recovering person and other family members to identify what triggered
the relapse in the first place — and find ways to avoid it in the future.

9 Facts About Addiction People Usually Get Wrong

There are a lot of misconceptions out there about addiction and alcoholism. Most of us were raised with certain perceptions based on the ideas of the culture that we were raised in. Our parents and other care takers tasked with our upbringing had their own notions, mostly based on nothing more than granpas’ opinion, and proceeded to pass them on to us. Here are some facts that hopefully, will help you on your personal journey learning to out grow your own upbringing and deal with the addictions in your life.
Nine Facts about Addiction most people get wrong.

Drinking Alcohol and Hypertension: Think You Are Not At Risk?

Pretend you are me. Forty-three, and always had chronically low blood pressure – almost to the point of hypotension. I used to get it measured at anywhere between 80-50 mmHg to 100-70 mmHg. Not so much anymore…

I’m not overweight. I eat right. I don’t really smoke cigarettes. And I exercise frequently, getting cardio at least 3-4 times per week.

But now, my blood pressure runs on the high side of normal to the low side of above average. But why? I realize that this is not hypertension, per say, but it does reveal how alcohol was gradually affecting my health – despite my engagement in other health habits.

Well, I am a recovering alcoholic. There’s no guarantee that’s the reason, but it’s a darn good suspect.

You see, alcohol and hypertension are intricately related. Drinking heavily can raise blood pressure beyond normal levels. Consumption of more than just 3 drinks during one occasion can temporarily increase your blood pressure. Repeated sessions of heavy drinking can lead to long-term effects.

The good news is that cutting back or stopping altogether can help bring blood pressure down. Systolic pressure (the top number) can fall by 2-4 millimeters of mercury (mmHg), and result in a reduction of 1-2 mmHg in diastolic blood pressure.

Also, alcohol is very calorie-rich, and often contributes to weight gain – another risk factor for hypertension. This was not my problem, but it affects many, many adults in the U.S. If you are overweight, cutting calories and losing weight can help, as well.

Cutting Back
However, heavy drinkers who are concerned about blood pressure should slowly reduce how much they are drinking rather than quit abruptly. This is because they are at risk for a sudden hike in blood pressure during withdrawal.

However, detoxing in a medical facility is highly preferred. This is because a patient can quit cold turkey safely under 24-hour medical supervision.

Other Risks
And of course, in addition to hypertension, heavy alcohol consumption can lead to heart failure, stroke, and heart arrythmia (irregular heart beat.) It can also trigger high triglycerides, and contribute to variety of cancers, as well as liver disease.

Also, if you have a family history of high blood pressure, your personal risk of drinking alcohol and hypertension-related symptoms also increase.

“Alarming” Death Rate in Primary care for Opiate Abusers

Patients with opioid use disorder (OUD) who are seen in the general healthcare setting are more than 10 times more likely to die than their counterparts without OUD, new research shows.
An analysis of electronic health records (EHRs) for more than 2500 patients with OUD who were treated at a major university hospital system showed a crude mortality rate of 48.6 deaths per 1000 person-years — a rate that was more than 10 times higher than the expected death rate in the general population for individuals of the same age and sex. The data covered an 8-year period.
“My original thinking was that the mortality rate could not be very high in the general healthcare setting because general healthcare centers are supposed to have more comprehensive health services, and most people are insured. But when I saw such a high mortality rate, I was shocked,” lead investigator Yih-Ing Hser, PhD, professor of psychiatry and behavioral sciences, David Geffen School of Medicine at the University of California, Los Angeles, told Medscape Medical News.
The study was published online April 20 in the Journal of Addiction Medicine.

Too Little, Too Late

Treatment of OUD has traditionally been delivered in specialty addiction centers, such as methadone treatment programs, “isolated from the primary care system or general medical systems,” the authors note.
Recent healthcare reforms through the Federal Mental Health Parity and Addiction Equity Act and the Affordable Care Act have led to an expansion of services for substance use disorders (SUDs) in primary care. Although most clinicians in the general healthcare system are aware of the risk for elevated mortality among OUD patients in publicly funded SUD treatment settings, they “do not fully appreciate the mortality risks to their patients,” the authors note.
To investigate the mortality rates of OUD in the general healthcare environment, the researchers studied the EHRs from a large university health system from 2006 to 2014. They identified 2576 patients, who ranged in age from 18 to 64 years at their first OUD diagnosis.
They also obtained mortality data from the National Death Index of the US Centers for Disease Control and Prevention. The duration of follow-up was from either the time of first OUD diagnosis to death or to December 31, 2014, for those still alive.
During the follow-up period (a mean of 3.7 person-years), there were 465 (18.5%) confirmed deaths, yielding an all-cause crude mortality rate of 48.6 per 1000 person-years.
Individuals who died were older at the time of first OUD diagnosis (48.4 vs 39.8 years) and were more likely to be male (41.7% vs 31.6%), black (11.2% vs 6.8%), and uninsured (87.1% vs 51.3%). The mean age of patients at death was 51.0 years (SD = 11.0).
Deceased patients were more likely to have been diagnosed with other co-occurring SUDs (particularly SUDs involving tobacco, alcohol, cannabis, and cocaine). Drug-related problems represented the most common cause of death (19.8%). These included accidental poisoning or drug overdose, intentional poisoning, and alcohol use disorder or drug use disorder.
Physical health problems associated with death included heart disease, respiratory disorders, hepatitis C virus (HCV) infection, liver disease, cancer, and diabetes.
Cardiovascular disease and cancer were the most common physical causes of death (17.4% and 16.8%, respectively), followed by infectious diseases (13.5%, with 12.0% HCV and 0.8% HIV), diseases of the digestive system (12.2%, with 4.9% alcohol-related liver disease), and external causes (6.7%).
HCV (hazard ratio [HR], 1.99; 95% confidence interval [CI], 1.62 – 2.46) and alcohol use disorder (HR, 1.27; 95% CI, 1.05 – 1.55) were the two statistically significant and clinically important indicators of overall mortality risk.

Lack of Screening

The overall indirect standardized mortality rate of 10.3 (95% CI, 9.4 – 11.3) represented a mortality risk that was more than 10-fold higher than that of the general population, after adjustment for sex and age.
The researchers call these findings “alarming,” suggesting that they “may reflect several past and current issues with current healthcare delivery systems in identifying and addressing OUD problems.”
“The general healthcare system has not been well studied with regard to substance abuse,” Dr Hser noted.
“Patients in this setting are much older at diagnosis than in publicly funded settings, and they have much higher morbidity and morbid conditions,” she said. “But general healthcare providers are not sufficiently screening for addictions, so it comes very late in the process for the person to receive appropriate interventions.
“Even when patients with OUD are identified, these clinicians may not have the resources to treat them, because general systems usually do not have addiction specialists on board,” she added.
The responsibility does not lie solely with individual practitioners.
“The timing is perfect, because the 21st Century Cures Act that former President Obama signed is now dispersed throughout the states to improve access to medication-assisted treatment. Policy makers and healthcare systems in each state need to start talking with each other and come up with a better plan to improve the infrastructure, train the physicians, and provide support when they need it,” she said.

More Training Needed

Commenting on the study for Medscape Medical News, Daniel G. Tobin MD, assistant professor of medicine, Yale University School of Medicine, and medical director of adult primary care, the Saint Rafael Campus, Yale–New Haven Hospital, described the study as “meaningful” but recommended caution when interpreting the findings.
“The study analyzed data from electronic medical records and identified people with opioid use disorder based on coding, which is a study limitation, because the coding had to be done correctly,” said Dr Tobin, who was not involved with the study.
“If clinicians did not include the diagnosis in the chart or did not code correctly, the number of opioid users might be underrepresented in the data,” he said, “leading to an overestimation of mortality rates in OUD in the general healthcare setting,” he explained.
Nevertheless, he said, “the study does show that having this diagnosis is associated with a high risk of mortality, and that the mortality is not necessarily due to overdose, which is the general conception of mortality from OUD.
“Since the patients in the study were identified roughly 5 years later than in addiction centers, these 5 additional years can lead to many health problems. I agree with the authors’ conclusion that the later the diagnosis is made, the more damage is done, so one interesting take-away is that we have to diagnose and treat OUD as soon as possible,” he said.
He agreed that more money, training, and infrastructure are necessary. “Not only do individual doctors need to take ownership, but there also has to be some infrastructure support so it becomes a routine part of primary care.”
Dr Hser added that clinicians in primary care settings can be an important force in shaping the nation’s effort to effectively address the opioid epidemic, but they need a lot of help. “They should get adequate training and get connected with an appropriate network that can help overcome many barriers that we are facing in treating addiction.”